Presentation of a quality management program in off-pump coronary bypass surgery

To increase the number of off-pump coronary procedures at our institution, a new surgical team was formed. The first 3 years of "learning period" were accompanied by a quality management program aimed to control and adjust the surgical process and to ensure the safety and quality of the procedure.

All patients were operated on by the same surgeon between January 2004 and December 2006; all procedures were performed under the following quality management protocol. First, a flow chart regulated surgical and anesthetic details. Second, an online file, named "disturbance file," was used to report work flow interruption, disturbance, and intraoperative events, that is, myocardial ischemia, hypotension, conversion to cardiopulmonary bypass, and any violation of the protocol. Each event was coded with 1 point and added to a score (the higher the score is, the greater the disturbance). Outcome parameters known as major events-major cardiac and cerebral events: mortality within 30 days/myocardial infarction confirmed by electrocardiogram or significantly high levels of total creatine kinase-myocardial muscle creatine kinase/reintervention within 30 days/stroke--and new-onset dialysis were also measured. Success was defined as freedom from any of those events and depicted in a cumulative sum control (CUSUM) chart. Outcome data and CUSUM were correlated with the intraoperative Disturbance Index.

In total, 490 off-pump coronary bypass operations were performed by the named surgeon during the study period. The 30-day mortality was reduced from 4.0% to 1.9%. Disturbance Index score of greater than 1 declined from 41.6% to 23.3%. All major cardiac and cerebral events declined. The CUSUM chart showed two critical periods during the learning period, which made an adjustment of the protocol necessary.

Quality management control is efficient in improving the postoperative results of a surgical procedure. A learning period is of cardinal importance for any new team wishing to engage in a novel surgical technique.